Akcan Akkaya et al. Pulmonary Edema after Hysteroscopy 375 International Journal of Medical Science and Public Health | 2014 | Vol 3 | Issue 3 SEVERE PULMONARY EDEMA DUE TO HYPONATREMIA AFTER HYSTEROSCOPY – RAPID AND FULL RECOVERY Akcan Akkaya 1 , Ahmet Karatas 2 , Abdullah Demirhan 1 , Tulay Ozlu 2 , Murat Bilgi 1 , Umit Tekelioglu 1 , Kadir Akkaya 1 1 Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Medical Faculty, Bolu, Turkey 2 Department of Obstetrics and Gynecology, Abant Izzet Baysal University Medical Faculty, Bolu, Turkey Correspondence to: Ahmet Karatas (akaratas1973@hotmail.com) DOI: 10.5455/ijmsph.2013.1212234 Received Date: 20.09.2013 Accepted Date: 06.02.2014 ABSTRACT Hysteroscopy is an important diagnostic and therapeutic procedure that can cause serious complications, including uterine perforation and dilutional hyponatremia. Hyponatremia itself may cause central pontine myelinolysis, and pulmonary edema, which could be dangerous. We report a patient who developed near fatal pulmonary edema, and hyponatremia during hysteroscopy. A total of 12 L irrigation fluid was given in 45 minutes and eight litres were collected. At the end of the procedure, the patient was suddenly being desaturated (Saturation O2 < %50) and huge amount of frothy fluid had come out of laryngeal mask airway, pulmonary edema was considered. The supportive treatment, mechanical ventilation and 3% hypertonic saline solution were used in the ICU. Initial sodium levels were below the value of 100mEq/L but after 12 hours it was reached 135mEq/L. At the 17th hour she was extubated and day after she healed completely. This case report emphasizes the importance of rapid correction of hyponatremia and pulmonary edema caused by excessive fluid overload during hysteroscopic surgery. Key Words: Hysteroscopy; Hyponatremia; Pulmonary Edema; 3% Sodium Chloride Introduction Hysteroscopy is an important diagnostic and therapeutic procedure that is used increasingly in last two decades. Although hysteroscopy is requiring less operating time, it is not entirely uncomplicated. Serious complications, such as pulmonary and cerebral edema associated with fluid overload and hyponatremia can occur during surgery. This condition is similar to transurethral resection of the prostate (TURP) syndrome which is seen in during urological surgeries. [1,2] The development of fluid overloading and hyponatremia is associated with several factors such as type and duration of surgery, type of irrigation fluid, and infusion pressure. Also it is stated that the risk is increases during menstruation. [3] Hyponatremia itself may cause central pontine myelinolysis, and may be an independent contributing factor to morbidity. [4] Rapid treatment of pulmonary edema and the replacement of sodium deficiency is vital. [5] Herein we report a woman who developed severe pulmonary edema, and hyponatremia during hysteroscopy. The indication for the procedure was ongoing vaginal bleeding for two months after the termination of eight weeks pregnancy. She healed completely without any sequelae. The patient has given us written informed consent for publication. Case Report A 20 years-old, (G2P1A1) woman was admitted to the gynecology outpatient clinic because of the ongoing vaginal bleeding for two months after the termination of eight weeks pregnancy. On transvaginal ultrasonographic evaluation, considering rest placental tissue, due to the irregularity of the endometrium, we decided to perform operative hysteroscopy. Preoperative physical exami- nation and laboratory tests were normal, Her height was 160 cm, weight was 50 kg, and her preanaesthetic physical status was American Society of Anaesthesiologists - I. In the operating room the standard monitoring was applied. The blood pressure and heart rate of the patient were 115/73 mmHg and 88 bpm, respectively. An 18- gauge intravenous (IV) catheter was placed and 0.9% NaCl solution was administrated at a rate of 100 mL/h. After administration of 10 mg of IV metoclopramide, the patient was pre-oxygenated, and anaesthesia was induced with midazolam 2 mg IV, fentanyl 50 μg iv and propofol 120 mg iv. Laryngeal mask (number 4) insertion was facilitated by 40 mg of rocuronium. Anaesthesia was maintained with 60% nitrous oxide and 2% sevoflurane in oxygen. The patient was placed in lithotomy position and a foley’s catheter was inserted. Irrigation fluid containing 5% mannitol (resectisol®, osmolarity (mOs / L): 275) connected to a lateral port of the hysteroscope was given under hydrostatic pressure of 400 mmHg. The procedure ended peacefully after 45 minutes. A total of 12 L irrigation fluid was given and 8 L were collected. During the procedure, some of the fluid escaped out through the cervix. At the end of the procedure, the patient was CASE REPORT